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This regimen is listed in the US as an alternative (rather than preferred) and not for men with CD4 above 400 (and women with CD4 above 250)In Europe it is in the recommended list with a warning for extra caution for men with CD4 above 400 (and women with CD4 above 250)

I took the HLA B*5701 test, the one that tells you if Abacavir should be avoided. I am negative : I can have it.

My readings are above 400 (440 to 535, depending...) therefore I was not expecting my HIV specialist to come up with this recommendation.

I have a number of concerns because of my age (getting close to 50), my blood sugar (was borderline before infection and now in the frank diabetes zone), low HDL (40 at conversion, now 35)but no AIDS related events, no confection, I am even CMV neg ! - no enough kissing, I suppose) , no BMI issues (BMI at 22.5), no liver problems, etc. I walk or jog every non-rain dayOne concern is brain/neurons issues in my family (Alzheimer, etc.)

Doctor says he likes the fact that one component (I think that is Abacavir) crosses the blood/brain barrier and therefore may have a protective effect

I looked into the available literature that compares various regimens and came to like this regimen better than others (due to my specific concerns).Actually I like it a lot. For example it may protect the brain while not having the psycho effects of Efavirenz (I should emphasize 'may').Seems to be a regimen you can stick with for a long time

Genotype says I have only one mutation (T215E) which forbids only AZT and d4TAll other options are open

PI s look a bit scary, not so much that they are, but because it seems to be jungle where the non specialist, like myself, can get lostAtripla is the king of the block these days and Raltegravir the new kid in town.Both taken with Tenofovir (not so much of my liking)

My doctor is a long timer HIV specialist who runs a HIV clinic (somewhat specializing in MSM). He has seen a lot...I asked him about adverse effects such a lipo and he raised his eyes, like he leaves that to oddsThe way he is... He seems to know that if I were asked to choose between damage to my brains or to my face, I would not sacrifice my being myself.So he does not ask. The way he is...

My doc says this regimen was demoted for adverse reaction concerns but is likely to be promoted back to recommended next year or so.

He likes it, I love it: there is no hesitation here.

Special caution means extra liver markers analysis with my blood work and extra visit to the clinic (every 2 weeks for the first 10 weeks). The doc is a big guy, very impressive, and very good at handling people's stress and anxietyThe extra visits are a bonus !...

Special caution means that I looked through the internet for people having used the same Viramune/Kivexa combo and did not find many threads

I like the idea that this regimen is a bit off-limits, a challenge custom designed just for me (although I am sure a lot of people have used it before me)

I am a bit concerned though and this is why I would like to hear from others who have used it. Please kindly share your experience with me and others

I am on the same regimen, ( Viramune and Epzicom) I've been on this regimen since January of 04. I started meds October of 03, And it's still working for me. I am 58, and started meds just about 18 years into being diagnosed positive. I also was taking Viread in that mix from around August 2004 until October of 09. I dropped the Viread, and everything is still going well.

My numbers were a lot worse than yours when I started. My t-cells were at 16, viral load @ 500,000 and a percentage around 4% ( in October of 2003.) My current percentage is 15% . I am currently waiting on blood test results from June 2nd.

The highest my tcells have been, ( since starting treatment) were the high 380's. I am currently in the low to mid 350's.

Viral load has been undetectable since November of 04 ( you can read this info on my signature at the bottom, And my CBC, Chemical profile , and Amylase , are always within range, However my cholesterol did take a jump up, after starting on meds, and I am on Simvastatin . I also have hypertension, so I am also on BP medication .

I deal with mild to moderate neuropathy, since starting on meds. Although I believe it's more Virus related.

I've never been on Protease Inhibitors. When I started on Viramune, it was a two step process. One viramune tablet a day for 14 days, then two tabs a day after that. I take my viramune at 8:00 AM and 8:00 PM . 12 hours apart. I take the Epzicom with my daytime dose of Viramune.

I get labs approximately every 3 months. It has been this way since I started.

The doc will be checking you liver panel during the first few weeks, just to make sure your tolerating the Viramune well, and will be monitored regularly after that. A small percentage of people can also have a allergic reaction to the Ziagen portion of Epzicom.

psychologically, I have a hard time with the entire thing and I feel encouraged by your posts.

I wish I could edit my post and correct the mistakes. Thanks for pointing them out.

Now, I can only post answers/reports on Sundays and today is Sunday.

I have noticed that a number of people who say that this combo works for them have been staying with it for a long time. I think one needs to get past these 6 to 10 first weeks.I have tried to create conditions that, hopefully, will be favourable:- I have managed to get all the critical work done before taking the meds- I have a weekly visit to my now-retired family doctor, who kindly spends some time with me (helps with the stress, the crying, the fainting, ...)- I'll be working from home for the next 6-10 weeks, so medication is not so much a burden to my work and to others- I am on 'house-arrest' : no going out, no sex, no alcohol

I take Kivexa (Epzicom) at 11:00 PM (moving daily by 15 min. in order to place it earlier in the day) and Viramune at 8:00 (the first 2 weeks, Viramune is only once a day)

I take Kivexa before bed because I was told it can be rough. Moving it forward 15 min. a day would place it at 8:00 PM when it is time for me to start taking Viramune twice a day (therefore 8:00 AM- 8:00 PM)

The first 3 nights/days have been absolutely perfect (no nothing). I was feeling great and relieved

Last night I felt bold enough and:- had a bit of wine- took the pill at 10:30 PM and went to bed at 0:30

At 2:00 AM I was awaken by stomach discomfort and noticed a slight pain on the liverPutting the nausea on a scale of 10 where 10 is the urge to throw up, I d say it was 2-3Putting the liver sensitivity where 10 is, say, pain, like you ate way too much chocolate cake the day before, I'd say 3Enough to keep me awake until 5:00 AMTook my Viramune at 8:00 AM Have been feeling so-so all day. Lying in sofa most of the day. Tension has been low all day : 100/60

I'll be more careful tonight in hope for a better night. These are pretty strong medicine after all...

Back in the days, people must have been weighting pros and cons, before deciding for the meds and may have stayed a long time with the viremia

Nowadays, it seems that the recommended strategy is to start early, which also means for some people starting with relatively high CD4 counts.

As stated earlier, I am starting this regimen with a CD4 higher than the cut-off value of 400 (for men, 250 for women). Controversial or not, I would not know...

In my case, it also meant starting 10 weeks after diagnosis. No much time to recover from shock

It is comforting to see you could recover to safer levels. It is good news to hear you can take Kivexa (Epzicom) at daytime. If things go well I wish I can do the same...

I'll report later (next Sunday?) about this (mild) liver pain and on going progress.

You can make corrections on your posts within the first day (or two?) after posting by going to the post and clicking on "Modify." Of course if someone else has already mentioned the "mistake" in a subsequent post it's best to leave it as is so that it makes sense to others when reading the entire thread.

It sounds like you are approaching this very sanely; please keep us updated on your progress.

I was started on this combination and found it very easy to take, aside from an initial rash that passed without note. Unfortunately, I developed resistance to all three drugs quite quickly. Some doctors say you can take both tablets of Nevirapine at the same time, i.e. two tablets once a day. This is a non-standard dose and I suspect one of the factors that contributed to my developing quick resistance so I wouldn't recommend it if it is suggested to you (at least, not while your viral load is detectable). The year after my resistance developed, the British guidelines were updated to say that Nevirapine shouldn't be used if viral load is above 100,000 copies (my viral load was 1.1 million copies). Oh well!

On Sunday, I was not feeling too well... My stomach a bit uncomfortable (although nothing serious)I was a bit worried about taking Kivexa when something crossed my mind:- my doctor in a previous visit had expressed concerns about my not drinking enough water (see my blood sugar issues)- I had read one post mentioning that increasing water intake could help- I had noticed that my weight had dropped overnight by 0.9 kG - 1.7 lb : that could be a bit of dehydratation

I theorised that ARVs are changing my metabolism and more water is needed.I did take much more water (1.5 litre) in the few hours left before Kivexa timeI felt better about taking my Kivexa pill and went to bed full of hope. But then, suddenly, the alarm rang...

It was 8:00 AM. I had fallen sound asleep and had a very good night

I can not say for sure that the water did the trick, but I kept very careful the entire week about it.

I also think that Kivexa makes me wake up in the middle of the night or wake up early. I was feeling the lack of sleep. Therefore on Friday night I took half a pill of Unisom (an over-the-counter sleeping pill that contains Doxylamine succinate) I very rarely use it (only when I have jet lag problems) and most likely a quarter of a pill would have been enough to ensure a good, undisturbed, night sleep.As a result I slept until noon (took my pill on time at 8:00, though) and again till 4 :00 PM. This is more than I would expect from a 1/2 pill of unisom and indeed I must have had a tiredness that went unnoticed and is now behind me.

Physically, the entire week went OK. a bit constipated, nothing worth mentioning. No rash, no vomiting, etc. The Kivexa drug information mentions that side effects usually occurs from the second week of taking the meds.I am now entering this 'dangerous' zone.

Since the diagnosis (therefore 10 weeks before starting the meds) I suffer from brain effects that scare the shit out of me.When it occurs, I feel like my brain is compressed in a helmet and floating on springs. It does not go away with the usual pain killersMost times it happens when I am stuck in my though because I have tumbled against the virus thing. (for example, writing these lines triggers it...). This was not happening before the diagnosis and had some occurrences before initiating the meds.To me, this sounds like self-inflicted stress-induced, not drugs nor virus related, but it leaves me a deep despair.I have fainted a lot (5 times in 10 weeks) and cried a lot too. I have less crying now, but (consequently?) more of the headache thing

I had expressed concerns about a potential weakness there to my doctor (obesity/diabetes/Alzheimer in my family)When I asked him why he chose a regimen that is normally NOT recommended in my case (it is written in the US guidelines that it is NOT to be prescribed to men with cd4 over 400)he said that he was interested in the potential protection for the brain and central nervous system.

This matter is still being debated and right or wrong I do not know if there is yet a final answer.

Nonetheless this link here below shows that ALL of my regimen compounds are crossing the Blood/brain barrier.

So not just Nevirapine and Abacavir (as discussed above) but also 3TC (to a lesser extend)

Whether this is a good thing or not I do not know, But I feel very happy (privileged?) that he had listened to my concerns and that we are doing something about it.

This is why I am so anxious to see me pass the 6 to 10 first initiation weeks. I suffer from an immense sense of guilt and stupidity about my infection and a failure to carry on a combo that I came to like would only add to it.

After now 10 days in the meds, a bit of stomach/liver discomfort that has apparently and so far disappeared, I am more upbeat

Reading the forums has been very helpful and I have the feeling that this regimen, once successful, can be carried on for many years.

It concludes:NVP demonstrates sustained efficacy and good safety and is very convenient to use as reflected by a high rate of persistency.

I must deeply thank those who are posting on this thread about their experience with this combo. There are so many posts about Atripla that I felt isolatedAll advises are welcome. If things go fine, I hope it will make it easier for me to come to terms with my fears and guilt.

BM, Rey, Inchlingblue : Thanks for the advises and support

I intend to take Viramune with the twice a day dosage, as this dosage has now been proven better for treatment-naives.On the long run, and if we ever get there, I will consider take Kivexa in the morning and then, I might consider Viramune as a once a day dosage along with the Kivexa.

Next week, Wed., I'll get my blood work and will start taking Viramune twice a day. Hopefully I should be able to post lab results soon. My current general feeling of well being makes me hopeful.

Since the diagnosis (therefore 10 weeks before starting the meds) I suffer from brain effects that scare the shit out of me.When it occurs, I feel like my brain is compressed in a helmet and floating on springs. It does not go away with the usual pain killersMost times it happens when I am stuck in my though because I have tumbled against the virus thing. (for example, writing these lines triggers it...). This was not happening before the diagnosis and had some occurrences before initiating the meds.To me, this sounds like self-inflicted stress-induced, not drugs nor virus related, but it leaves me a deep despair.I have fainted a lot (5 times in 10 weeks) and cried a lot too. I have less crying now, but (consequently?) more of the headache thing

I'm not on your same combo but I was getting very strong headaches before starting the HIV meds and they pretty much went away once I was on the meds and became undetectable. I think it was caused by the HIV itself.

I also had some of these headaches after starting on meds. It wasn't a daily thing, but they were severe enough at times, that I would be forced to lie down. I very seldom if ever get headaches any more. But I never fainted.

My working hours are flip-flopped from everyone elso. I work the 11:00 PM to 7:00 shift. I sleep in the day and awake at night.

I was taking epzicom at 8:00 at night, but found it to be a little intense. I switch it to 8:00 AM, and I usually go to sleep around 11:00 in the morning.

Yes, Make sure to drink plenty of water !! You can also have meals with these meds, your not restricted to food intake on Viramune or Epzicom, unlike Atripla. So, try having some food when you take your meds. It might help to ease the stomach situation.

I have fainted in public and fallen into tears quite a few times now (including before the meds).This creates a stress that reflects on my stomach/sleep etc.On Wed. after going to the lab for the blood draw, I was feeling so bad that I would not be able to drive back homeI paid an unscheduled visit to my doctor (a few blocs away)We did not have the lab results yet but physical examination was OK, so he told me to call to confirm if I could move forward, that is take Viramune twice a day.I said that I had the intention to do so and he kindly but firmly said that I should seek his approval before so doing.

While I knew Viramune should be introduced in a 2 steps process and needs to be monitored, I did not know that I should get doctor's thumbs up before continuing.Considering that step 2 should NOT be delayed any further than the initial 14 days, it means that one should be very strict in having blood drawn on Day 13 and have a visit to the doctor on day Day 13 or 14(my lab said they could give the results in a few hours, but I would not know if this is true for all labs). My blood work had happened on Day 13...

I reported all my stomach/stress problem. He said that this is most likely of psychic cause and referred me to the clinic's psychologist and also prescribed Prazepam (N05BA11) As of today, I have made an appointment with the psychologist, but I have not (and intend to avoid) bought the anxiolytic

I called the doctor on Day14 and he told me on the phone that the lab results are excellent and told me to carry on.

Referring to my post traumatic stress disorders he said that:We will have to find the keys to carry on

Yes Doctor, I am working on finding these keys !!!

There was something in his voice that told me he is very confident this will work and we should carry on ...Looking at the lab results, I also had a hunch that this is working. I will not speculate uselessly right now, but will share my thoughts once the real lab results (CD4 and VL) are available (in 2 weeks)

Strangely enough, from the very moment I had entered the clinic for this unannounced visit, most , if not all, discomfort was goneUpon starting viramune step 2, I felt safe, secure and have been feeling super since then.

Last Saturday night (Day 16) , I have had an episode that mirrors that of Day 4 : no sleep at all, constipation and feeling down the entire Sunday (today)

I have now learned a few things about of these 'side effects' on me: - they are very bearable (so far)- they will fade with time- Stress/shock induced should not be mistaken with meds induced - something really positive is going on inside my body

I know I was getting sick with all the stress and shock recovery... I finally allowed myself the anxiolitic.

Since then, every thing went smooth, smooth, smooth (a bit sleepy with that medication)

Went to the pharmacy and did not faint (for the first time since...)Went to the Lab and did not faint nor cry (for the first time since...)

Tomorrow is my scheduled visit to the Doctor and I cross my fingers (there is always a bit of commotion around this 'older' guy crying and fainting like a Diva, which is something I hate about this situation)

Tomorrow is my scheduled visit to the Doctor and I cross my fingers (there is always a bit of commotion around this 'older' guy crying and fainting like a Diva, which is something I hate about this situation)

This is true, I am finally doing real fine. All this stomach discomfort and headaches are gone.

I am quite sure that they were stressed induced.

Doctor prescribed Prazepam (goggle for :N05BA11 should you need more info). He said 10 mg in the morning and 10 mg at night. I'll do it for a few days then I will restrict to the Pharmacy/Lab/Clinic days.(actually, I already take only one 10mg pill a day)

Can you believe that I had to walk all the way around the block where my Pharmacists is because the mere fact of walking past it would throw me in tears (and ruin the day...) ?

Believe it or not I had to postpone lab visits because I fainted on the way !!! And I am (almost) fifty !(Doc says the younger generation takes it easier, I guess because they have NO IDEA what is was back then...)

Test and treat, they say... Easier said than done !

But you are right, the shock seems behind me now, and I must admit reading this forum has helped a lot

One thing you should keep in perspective, Eric, is that you live in a country where you have access to treatments and medications as part of a national health insurance pool. Even in the US there are many people who don't have access to meds and to insurance, not to mention the deplorable conditions in the developing world for anyone with any chronic condition.

For this last week, I have been doing absolutely fine !No nothing ... no stomach uneasiness and most importantly no brain/mind issues

As reported before, I thing that the fog or helmet feeling that I had was stress induced.

Doc asked me to take 2 times a day 10 mg of Prazepam. Says it is a baby dose. Makes me sleepy.Actually I only take 1/4 of the pills and now only when I feel the need for it. I haven't had to take it for the last 48 h.

Knowing that this anxiolitic does marvel on me (and cost less than 5 bucks for 50 pills) I wonder why he waited that long to prescribe it.I make this note for the new comer: do not hesitate to ask your doctor. stress induced brain pain could be misinterpreted for meds SE (by patient, at least)

DO NOT DRIVE when using these !!! The baby dose (as my doc puts it) makes me sleepy, and I was carefully NOT to take the pill on that morning I took the car for a long drivemy previous pill intake was 14 hours before. Nonetheless, while driving, I very suddenly went asleep and car drifted to the ditch. Apparently went in contact with the safety rail with a very small angle. Front wheel dub exploded, that woke me up (sure did !!!) and I took control again.

Not even a scratch on the paint ! I will have to change that dub ($20) and that it.

This is why I am now on a 1/4 dose and only when needed (and no driving!). Doc says this anxiolitic is the mildest you can have and may have varying effects on people, but that some people take as many as 10 a day without problems.

I would not know if my specifics are just myself, the combination of the anxiolitic and ARVs, or just a result of the mental exhaustion I must be suffering.

This long note just to say that I could have died last week from... a mere car accident !...I still recommend to mention use of a stress relief medication to doctors when just diagnosed or when starting the meds.Just be Extra Carefull.

Tears of joy************

Now I have a new problem : tears of joy !!! sudden outbursts (only when by myself...) (Boy, I even did not know this 50 year old guy could be sooo sissy...)

And there, believe me I take no action against these !

I already sensed the lab results would be good and I had even anticipated a good CD4 reading.(due to my age, I had told myself to be modest in my expectations, but still...)

I was not expecting this:

Lab results ***********as of July 5 2010 (under brackets are the latest known values most of them as of May 28 of beg. of May 2010) Meds started June 9

That a 2.06 log decline in less than 30 days! No wonder I was tired !(assuming 5 liters of blood that's 340 Million virions KILLED - GONE - KAPUTT)

I could not have hoped for better! Doc was kind of apologetic for the modest rise in CD4, saying that I have been on half dose of viramune for the first 15 days...

Doc! Are you KIDDDDING ??? that is a 210 increase (about 50 %) coming with a comfortable restoration of CD4% (+ 50% of the percentage) as a bonus.

May be that is because it did not see me burst in tears (again... and he is my favorite victim at a rate of 4-5 times/visit - but never fainted there)And for a cause : I KNEW it was working on me... (and I had a 1/4 pill anxiolitic before too...)

It was only when I reached home that I started realising that the results are good because the other values are very good too!

OK... I know I should be carefull about expectations as one never knows what kind of tricks the virus may have in store

Doc asked what I think about Side effects. Said that week 2 was a bit rough but all this is behind me now ...Not so fast, he said... Allergic reaction may still occurs and I have to wait another 6 weeks to claim victory (over potential adverse reaction to viramune or Abacavir)but, yes, I am 2/3 done... And another 6 weeks to go...

The CD4 increase: I knew it !*****************************(kind of...)At Week # 2 I had an intermediate lab results that did not have CD4 nor VL ...Nonetheless, reading through this forum and posted data, I have noticed that in *** most*** cases (but not all, I must admit)CD4 %, which is usually a less fluctuating value, would at least remain stable (read: will not decrease) right after the initiationSo I took my latest CD4% (20%) and the total lymphocytes reading at Week #2 (which I had: 3100), multiply and got a prospective value of 620 (assuming CD4% would not change)I think the assumption that CD4% does not change is valid for a a short range of time, but hey, it gave me a number that gave me hope and relaxed my stress !!!

My Doc says he is not too much into maths and stuff, and as long as I this had made me feel better, then it is fine with him... (I sure think that me not bursting into tears as usual was already good enough for him)

Future plans************I take viramune at 7:00 AM and 7:00 PM , then Kivexa at 22:00.Doc says I am over doing it : I could take Kivexa at same time as Viramune ... Well, doc, see, I do not want to stress my liver too much.Even if it is an overkill, it does not bother me that much (at least in the beginning)In 6 weeks, if I pass the SE danger zone, then I'll try Kivexa in the morning (some people have had a hard time with this)Then see how it works for me. On the long run, I am concerned that I might forget a Kivexa dose, go to sleep and then it is too late...If you miss it in the morning and realize it soon enough, you still have time to do something about it.2 takes a day does not bother me much. What I fear is a tiring day at work, a glass of wine and... falling sound asleep in the couch...

Doc said that if this works for me, after a while we could even take the 2 viramune in the morning (We ?, ???, ?????????)He said that the Viramune manufacturer is already working on a once a day pill.

We ??? (some more TEARS of JOY)******************************

Doc, do you realize you took care of me, gave me a combo that is NOT the most prescribed (Atripla) (though I admit your choice suits my concerns)Doc, do you realize how much I admire you, for your work, for your calm, understanding of people, your deep and comforting voice ?Doc, do you realize I am scared to death (and of...) with the SE (that did not come so far) ?Doc, do you realize I talk to you all night long ?Doc, do you realize you just said that we could take all those pills, all at one time, at 7:00 AM, then get back to sleep for a little while and forget about all this and start the day as usual?

Doc, do you realize you just said WE ... Like... like... See what I mean ? ... WE (like in ... ) ???

Oh Boy !!!, I had to refrain some more TEARS of JOY and rush out of the clinic ...

Some days, I 've been tired... I think it is exhaustion resulting from stress. Actually, I am taking the anxiolitic far less than the prescribed dose (I take 1/4 of a pill, only when needed, whereas doctor prescribed 2 x /day)I think I may have taken 1/4 of a pill only twice this past week. Still does the trick !!!

Looking back, I think that most of what I had described above was due to stress. This is important to note because there are not that many patient posts on forums or the Internet about this combo. I guess that is because people usually have nothing to complain about it.

The new US guidelines says that Viramune should not be given to people with higher CD4 (>400 for man and 250 for women). So people, who, like myself, have been offered this combo at 400+ are kind of worried.

As for myself, I keep my fingers crossed until the end of the initial observation period (10 weeks); in my case, end of Aug. 2010. But so far, so good ... Week 2 and 3 have been a very little tough, but no big deal. Nothing of interest since.

Someone, who was concerned with Viramune at 400+ has posted on TheBody:

I will gather some of the information I had collected when I was asking myself the same question as he does and will post next week.

It is kind of hard to say, but, reading through patients opinions, I've almost never seen any complaints about Viramune whereas the number of people complaining about brain SE with Efavirenz seem to be quite many (some people say as high as 20%)So, yes, Viramune (and Kivexa, in my combo, alike) require close monitoring at the initiation (because of allergic reaction of the liver), but I guess that once you've passed that, then, it is OK (I hope...)

Thnx for the condolences. Even now there is always time to help out, so... here is my experience.I have been on this combo, + Viread since about 4 or 5 years now.I am extremely happy with it. It has been the easiest combo to take for me, once daily.

I do not have any side effects at all.I may experience a light neuropathy occasionally, but that only occurs if I have not had enough sleep or I wake up in the nigth. This occurs vere rarely though.

I once was at 7 CD4 count and a viral load of millions.I am now undetecable since 1996 and my t count is currently at 750, the highest ever was 950.

Now, consider yourself lucky to be on it... I have been on MANY other combos, of which the one with truvada was sheer horror. Many others gave me nausea, liver or kidney problems and fatigue. This one is just .... a dream come through for me.

I surely hope you can stay on it...

xx hermie

Logged

Diagnosed in 1987 and still kickingViread, Kivexa (Epzicom),Viramune once daily

I thought Herman would chime in , when he read this thread. He was the one I mentioned in my first response to you in this thread. I want to add, that I was also on Viread, along with Viramune and Epzicom. I dropped the Viread around October of 09, and so far so good.

This weeks I have been working on collecting some articles about hepatotoxicity due to Viramune (nevirapine) in order to document my thoughts, especially with regards to the message left by someone on TheBody (see my post above)

See, I was offered this combo eventhough I was CD4 > 400 (and male). Guidelines for the Use of Antiretroviral Adults and Adolescents; by DHHS, dec 2009, says no, no, no... So like this person who had posted on thebody I was highly surprised

Your opinion about this combo has been (and still is ) very dear to me during this initiation period. Collecting information, I found reports that contradict the reports on which DHHS based their limitations.

I will therefore put a bit more time into it before I write any further.

As for myself, this week's report is going to be short:- I have to go to bed early, leave early for blood work tomorrow. It is going to be more fun when we have the results...- my general status is improving...

Until last week the only subject of concerns where:1- I am constipated2- I sometimes have a fog effect in the brain (this immediately makes me very worried and sad)3- I sometimes have a heat effect in the back of the neck (flu-like, duration 2-3 hours)

1 is since I take the meds (never happened before); 2 is since I have been diagnosed (never happened before); 3 dates from way back and I know I had this before I got diagnosed, so may be its the virus that does that2 and 3 are typically every other day, always starting around 4 PM, lasting 2-3 hours. This is bearable but since it is recurring, I found it very depressing.

I have finally resorted to take the anxiolitic once a day (1/4 of a pill max per day instead of prescribed 2 pills a day). I think it helps!

I suspect there is some kind of interaction between the anxiolitic and the meds because the only day where I took it at my Kivexa time (10 PM), I had a bad night (nausea, tachycardia)I now take the anxiolitic at 4 PM. and for the last 5 days I have not had any of the 2 and 3 effects.

In other words, the last 5 days, my only (little) problem has been constipation. All other effects have receded. I will carry on with the anxiolitic for a while and then we will see.

I am very hopefully. I am very anxious to pass these 10 weeks initiation (I am at week 5 or is it already 6?). Like Hermann said, I would very much like that this combo works for me, because from all I have read, while this combo may not be for everyone (hepatotoxicity in a very few % of patients), if you can have it seems to been an easy enough combo.

I try to cool down and be rational. I know I am panicking over details and it does me worse than good. My virus already has one mutation (although not limiting my choices too much) but still... I just can't stop thinking that it is an experienced virus. Because my virus is resistant to older meds (AZT and d4T) I can't stop myself thinking that, in the transmission history, there is someone who was under these older meds and transmitted the virus.Someone who KNEW he or she was infected and somehow carelessly passed it on. I wish I would not have to say so but this simple thought fills me with hater or rage, and then I know the brain frog might come (I successfully keep it under control thanks to the anxiolitic)

I have a (difficult) anniversary to pass and was looking forward to a bottle of champagne for, you see..., good results.

Cd4 at 800 should be more than enough to be happy with. It is just that I can't suppress the idea that my virus could turn out more tricky than I thought. Spoils the celebration, kind of...

Also found out a significant deficiency in Vitamin D, but that should be expected and I think they have something for it.

Vitamin D3 is at 11 ng/ml which is very low. May be the reason why I feel exhausted...

You are very right... I should just cool down... I wish I could. Good to know you're around

While WHO considers that a good immunologic response is a good marker of virologic response, they found out that it, alone, is not a good enough substitute/predictor.

The surprising finding was that another readily available set of data, when combined with the immunologic response, provides a pretty good model.

The amount of Hemoglobin in RED cells, that we can imagine being how much red a red cell is, when combined with the immunologic response in a simple calculation, is a pretty good substitute to virologic response measurement (using VL)

The researchers themselves seem to be pretty much surprised with their findings

In addition to current CD4 count and cd4%, you only need to know MCH (and, of course, values at baseline). This value is usually reported in basic lab reports (I found it in mines)

I made my self a small Excel sheet, which I'd be happy to post if I knew how...

In other words, things may have improved more than I originally thought...

The lowdown is that I am using the J. Hopkins formula as a predictor, whereas it is not intended to be. (it is intended to be a substitute in case VL can not be measured at intermediate end point of 4 months)

And odds are just what they are... odds. Also, I think that the findings of the researchers at J. Hopkins are , as they state: surprising !

Still going through the above calculation cheered me up and I have had a much better week.

Thanks buddy!****************Your support helps in these difficult times (see below). Let me add one side comment to one of your other posts: you said somewhere: I work out pretty regularly but the other day I jogged for the first time in over 25 years! I'm 48 and did 1.66 miles. My thigh muscles hurt the next day but in a good way and right after the jog I felt elated and invigorated. I'm pretty sure my cerebral blood flow must have improved.

Same here... I had let go of jogging but recently go back into it with one of the variants called slow jogging: it's jogging with very small steps. Someone walking fast would actually pass you.Think of Mr Bean jogging and you have it. It was recommended to me as burning 60% more calories than walking, improving blood circulation as much as regular jog, but, avoiding the fatigue/stress on muscles that is in fact due to a raise in one acid in your blood (lactic? urea? I do not remember...)It is worth a try, if you do not mind being ridiculed by kids...

Side Effects*************I 'd wished I could say that every thing is OK.

But, unfortunately not the case ... On the Liver, everything seems OK, so far.

On Wednesday, from quite early in the morning to late in in the afternoon, I got this intense burning sensation on peripheral skin. Just like you have been sun burnt. Badly ...There was no rash, skin (especially on legs) was a bit itchy, not even red, but that was not the problem: it was intensively HOT. Like a fever but not internal. Just on the surface.(temperature, measured under the tongue was normal - I had some tachycardia, too)

That was not severe enough that I would rush to my doctor or the ER, but a bit more intense than just 'moderate'. Went away with the evening

The next day happened to be fever-like but less intense, and the day after was also hot, but again less. Despite bearable, there is no way I could keep going to work under these conditions (actually on Wed. I had to skip work)

Saturday, I only had the 'usual' heat in the back of the neck and noticed, I was always feeling better (actually feeling fine) when in shops/malls or museum (because they have air conditioners) ,and it starts being 'bad' when I get out in the summer wether ...At nights, I 'am fine... So *** may be ***, it is a thermoregulation problem

It scared me because it was burning hot. I was expecting a rash to come out anytime, but it did not... If it is a onetime thing, then lets forget it. If it ever comes back and again, it is going to be intolerable.I am now well into the the 18 weeks surveillance time, so I just hope I can get by.

Today, Sunday, weather is cooler and me too !!! Today is a great day (at long last !). Maybe that is the trick (outside temperature)

I have gained some weight (2 pounds) despite working on it closely

Towards Once a day***********************Retrospectively, it way look strange that I was taking this combo in a 3 times a day (whereas it is a twice a day), but both Viramune AND Kivexa have liver/rash side effects so may be it was not such a bad idea (say, in the beginning)I was worried that it was because I am now taking Viramiune and Kivexa both at 7:00PM (I also have one viramune at 7:00AM). I decided that if that burning effect was back the next day, I would separate the timing a bit (as I was doing until last week Viramune at 7:00 and Kivexa at 10:00 PM)

Taking Viramiune and Kivexa both at 7:00PM (at the same time) is a significant improvement on my daily routine. And of course, I am looking forward to the promising Extended-Release Formulation Of Nevirapine

If the extended release is approved, if I can stand the combo, and if it works on my virus, and if the HDL / LDL / Blood Sugar improvements are confirmed, then this combo is a winner (for me...)Still a lot of ifs, but the more I advance, the better the outlook.

About Numbers*****************

One of the specifics of this combo is that you get more blood tests than other people (to monitor liver parameters).What I like in the article I quoted last week, is that regular blood tests could be used, to a certain extent, to prioritize the more expensive CD4 + VL tests in areas where these tests are challenging (cost, availability...)In the same fashion, I am using MY numbers to validate a predictor or estimate for CD4 and CD%

The computation goes like this:- take your latest known CD4%- multiply to your current lymphocytes count to get a first estimate of CD4 count- divide by your previous CD4 count - apply this ratio to your CD4% to get your ESTIMATED CD4%- multiply this ESTIMATED CD4% with your lymphocyte count to get your ESTIMATED CD4 count

Since I coined this algorithm by my own, I am taking advantage of extra CD4 + VL test availability (at my OWN cost) to validate, at least on myself...As of today, I only have 2 sets of data to play with and they are looking good.

This simple algorithm, if valid, could be combined with the estimator that J. Hopkins researchers came up with and may help:- those, like me, who have intermediate CBC and are anxious to know more about they immunologic/virologic response- those who have to prioritize CD4% assay and VL assay in situations where it is not easily available

In this regimen, numbers play a more important role than in some others:- they are thresholds in DHHS guidelines (VL must be less than 100.000 ; CD4 count less than 400 for males, 250 for females)- Liver parameters must be monitored (ASAT, ALAT , CCT, etc.)- Oesinophiles are something my doc was showing some concern about (I'll get back to it after I understand better), but that is yet another number to monitor- HDL goes UP (which is a POSITIVE side effect)- LDL goes up (while not so goodnews, the protective effect of HDL makes it acceptable): these are again more numbers to understand- blood sugar/insulinoresistance (again more numbers) must be monitored for people at risk, like myself (in my case showing significant IMPROVMENT)

Physically, nothing to complain about and the week would have been perfect if I did not have this :

I had to visit a customer located quite far a way and had a lot of driving. It was hot and tiring. while driving I had this brain effect (which I have had before) that is a combination of brain-fog and contraction of the jaw.

It is not painfull per se by annoying. It usually goes away after 1-2 hours, but this time it lasted continuously for more that 48h. Because of the driving and customer call, I could not take the anxiolitic.

Contraction of the jaw during the night is a pain and I had to place some cloth in the mouth to get to sleep.

After I came back home the fog disappeared but not the contraction, which I again have even right now. I take the 1/4 of a pill anxiolitic (with much hesitation); helps a bit, but I do not dare take more because it makes me sleepy.

I have moved my Kivexa intake to the morning (I moved it forward 6 hours, then another 6 hours earlier the next day, therefore moving it from 7 PM to 7 AM)

The next 2 days, I had some kind of mild diarrhea twice (was a bit liquid and pressing). No big deal but if I ever have to do this again (time difference when travelling, etc.) , I should know and be prepared.

When the weather is cooler, I get better. I 'll make sure to get an air conditioner installed before next summer.

This jaw contraction may be due to taking Kivexa in the morning. I'll give it some time and we will see...

With this combo I have a choice of taking Kivexa in the morning or in the evening since I have to take Viramune twice. I , now, take my meds twice a day, which is a great improvement and I can go to a once-a-day, it will be even better !(and I can then try placing it a the most appropriate time of the day, whereas, now, I still have to have a 12 hours difference between the 2)

"there is some evidence that switching from a PI to either the non-nuke nevirapine (Viramune) or the nuke abacavir (Ziagen, ABC) may improve insulin sensitivity and lower glucose"

Before infection my blood sugar was borderline and I could feel the effects of this pre-diabetes state (tiredness after meals, strange feelings along the legs)Fasting blood sugar was hovering between 1.0 and 1.5 which is (depending on doctors, the threshold for diabetes)After infection, Blood sugar went up to 1.56 and remained there.Right before meds, Glycosuria was 5.6 g/l (whereas there is none in healthy individuals) and Microalbuminuria was 45 mg/l (reference value : less than 20)(in other words urine is brown-red)Before starting the meds, Glycated Hemoglobin (aka A1C or HbA1c) was at 6.4, which is also above the defining limits of diabetes.In general, the reference range (that found in healthy persons), is about 4%–5.9%.The International Diabetes Federation and American College of Endocrinology recommend HbA1c values below 6.5%, while American Diabetes Association recommends that the HbA1c be below 7.0% for most patients(http://en.wikipedia.org/wiki/Glycated_hemoglobin)

Blood sugar is raised by infections/inflammation, therefore, frank diabetes should be declared on non-inflammated state.Therefore whether I was already in the Diabetes zone or not is debatable, but, honestly, was a real concern

A1C works as an estimate of average glucose over the previous 6 (?) months

The approximate mapping between HbA1c values and eAG (estimated average glucose) measurements is given by the following equation:

eAG(mg/dl or g/l) = 28.7 × A1C − 46.7

I should wait until my A1C stabilizes (which may take a total of 6 months) before I can use the above equation.As of today, it would give:May 2010 : A1C = 6.5 gives eAG = 1,36 (consistent with my Fasting Blood Sugar : 1.52)end of June 2010 A1C = 5.8 gives eAG = 1,19 (consistent with a decrease of my FBS to : 0.93)end of July 2010 A1C = 5.6 gives eAG = 1,14 (consistent with a decrease of my FBS to : 0.81 - my lowest ever, by far)

Relative to the control subjects, A1C underestimated glucose by 29 +/- 4 mg/dl in the HIV-infected subjects. Current nucleoside reverse transcriptase inhibitors (NRTIs), higher MCV and hemoglobin, and lower HIV RNA and haptoglobin were associated with greater A1C-glucose discordance. However, only MCV and current NTRI use, in particular abacavir, remained significant predictors in multivariate analyses. Fructosamine more closely reflected glycemia in the HIV-infected subjects. CONCLUSIONS: A1C underestimates glycemia in HIV-infected patients and is related to NRTI use. Use of abacavir and increased MCV were key correlates in multivariate analyses. Fructosamine may be more appropriate in this setting.

If data are biased by Abacavir, then previous indication that Abacavir is good for blood sugar may have to be revisited

Thus, my numbers *** may be *** biased and may warrant further analysis.

Nonetheless, I am quite certain that blood sugar has decreased significantly:- my urine is (almost everytime) clear- I do not feel the post prendial sleepiness- Glycosuria is not to be found in my urine sample- I just can feel it

I'll try this Fructosamine test, just to make sure how much my blood sugar has improved

If, as I think, it has improved this much that I am not in the diabetes zone any more, then it would be a MAJOR POSITIVE side effects of this medication on me. Then I will not have to take Metformin

Works for me, may be not on others.

Doctor was impressed by the change in blood sugar and A1C and asked me what is it I had done to get this (as if I was taking some medication or ancient recipe without telling him...)

Well no, doc, the only meds I've been taking are YOURS. Of course, I have being dieting (as usual, as my family is mostly obese, as I was) even more carefully and have lowered the carbo hydrates intake even more...Some papers I had read seem to say that a proper low carb diet (and regular exercise) actually performs better than metformin

Possible causes for my blood sugar improvement since I started the meds:- inflammation due to HIV has lowered- this combo- my diet (more carefull on carbs...) and exercise

I may never know which is which, but since diabetes is such an impairment of life (especially when getting older), I am quite hopefull that this will hold with time !

Since there is an overwhelming number of people using Atripla, I do not find much patient's comments with regards to this regimen and diabetes.

Have you seen your blood sugar IMPROVE or WORSEN ? I'd like to know !

This regimen is potentially risky and risks have to be carefully balanced with potential benefits. If there is a benefits there (for those concerned) , then it is worth it!

I have a neighbor, that I haven't seen in probably 6 months. Because of my schedule we miss each other. Well, I seen her last week. This woman is about 60 years of age, and was always on the heavy side.

I couldn't believe it !! She had slimmed down, lost she said ( 65 pounds) and she looks fantastic. Looks like someone much younger, looked like a totally different person.

She was taking insulin,for diabetes, but as a result, she no longer needs it, everything is naturally undercontrol. She has changed her diet completely, she's joined a gym, and goes three times a week, and says she has never felt better!

Eric, I think if you continue to watch you diet, get regular exercise, you'll continue to see improved results !!

As far as the Kivexa making the jaw contraction. I never had this problem with Epzicom.

Yes, get that air conditioning !! It's been a long hot summer, and still got more to get through.This heat has been brutal for a lot of us. I know I can't spend that much time out in it.

(Aug. 22) I am still having this jaw contraction thing and, honnest, it tires me. Other than that, everything is fine (still a bit constipated)

Yesterday, as I was preparing my pill box for the week, I just do not not why, some sort of reflex, I took the pill (Viramune).I was preparing my pill box for the week and there it was in front of me, so, I (stupidly) swallowed the pill. 3 Hours ahead of schedule. No big deal.During the night I had a bad episode of jaw cluntching. Bad. Cried a bit (something that has not happened for quite several weeks now). Because I am fed up with it.I have tried several times the anxiolitic, but it puts me to sleep. So I did not use it (I had to make sure I wake up at 5 AM)

This morning, thus, I had to take my Viramune 2 hours ahead of schedule at 5 AM:00, and tonight, it is going to be 1 hour ahead and that is it...Of course, I took my Kivexa on time at 7:00 AM. Thus there has been a 2 hours difference between my Viramune and my Kivexa. Just by chance, pretty much like I was doing in the beginning.

It seems to help a bit on the jaw thing... May be a timing issue. Maybe it is too early for me to take Viramune at the same time as Kivexa.Otherwise taking Kivexa in the morning (and along my viramune) did not seem to produce any problem, and it was very handy...Maybe... When I had mentioned to my doctor that I was taking Viramune at a different time than Kivexa, he shrugged, as if it was pointless. Maybe not so. May be it was a good idea after all (at least at initiation)

I can live with the idea that I should give it time...

It is just unexpected...

Tomorrow I have some blood work... Will know more soon and I 'll be visiting my doc on Thursday.

Doc says my jaw tension issue is PTSD (stress). I said I do feel much better about the whole thing now and that I have no reason for anxiety (I have even dropped the anxiolitic).(BTW, I am back to taking Kivexa at same time as Viramune)

He insisted, saying that I have been through a lot recently...He was smiling (out of sympathy, he is such a nice guy, truly is, charming eyes, too...)I WAS NOT (I am fed up, included with myself...)

Our local guidelines for virologic success requiresmore than 2 log VL decrease and/or less than 400 at 3 months (i.e. 13 weeks)decrease is : 4.82 - 2.35 = 2.47 log. and VL is 220. So everything is fine is it not ?

Blood work was done 2 weeks ahead of schedule (Doc visits are out of pace because liver monitoring is at 2 weeks, then monthly- this is why it was done at 11 weeks)

If this jaw tension (I have less of it now, but still there) is due to stress, then the cause might be my concerns about VL (went down very fast, then kind of slowed down)

I did not want to ruin the day and did not mentioned that I had some concerns about this VL

Doc said that CD4 where much better than one could hope for (and some how wondered why)He seemed happy

Doc expresses concerns, hesitates a while because blood drawn a bit early, mentions that Nevirapine (Viramune)has a low barrier to mutation, calls the biologist over the phone and orders an extra drug resistance test (genotype) on last month results (where VL was 700, therefore, still high enough, this time blood sample is at VL 220, too low for genotype)

Oh Boy, this infection is a journey of sorts !

Doc wants to cool me down and says we have solutions in case...

And here he is, discussing about a possible switch to PI (potent, once-daily, but not so lipid friendly) or Isentress (lipid friendly but twice a day)

Holy shit !!! (excuse my French...). I came in, trying to focus on the beauty of the results, in order to reduce my stress

And here where are: he is laying ground work for resistance and switch talk.

Strangely enough, it does not ADD stress but rather reduces it since I know he is taking a very cautious step (genotyping)

I just knew it. I (kind of) knew my body would respond well, but virus be a bit more tricky (one mutation already registered)

Next visit in 3 weeks (well enough to get that resistance test done, he said)

I promised myself to go to the lab at month 3 sharp (09/09) and get a CD4+VL and bug the biologist about the genotype.

I sure want to have time to review my options before the next visit...

I left , a bit disgrunted ... then rushed into the local bath house for a cheering up (protected) fun, that was actually quite enjoyable.

Nothing new. Jaw crunching still around; may be a bit less noticeable. Doctors say this is stress... Well this has been lasting since Aug. 12 (now 3 weeks!)It better stops or I'll start questioning all these meds flowing through my brains.

Fructosamine results came back at 250. This is within range. I'll use this to evaluate whether the above mentioned report stating that Use of abacavir and increased MCV may lead to underestimation of glucose level if using glycated hemoglobin

because my CD4 cell counts >440 cells/mm3. (I had 3 readings: 440,535,450), I sure want to see the 'clinical benefits'

Generally speaking, Viramune is said to be beneficial for HDL (same is said for Abacavir) while only slightly increasing LDLIn my case, and as of today, this is confirmed

Same with Abacavir, I sure want to confirm the benefit outweighs the risk.Abacavir is said to be good for people with diabetes concerns.In my case, and as of today, this is confirmed

But, that holds true ONLY IF the medication is not biasing the lab results ! (cholesterol/blood sugar)

Seen from my doctors perspective the advantages are:- more penetration into CNS (reduces VL in the brains)- reduced VL in semen

OK Doc ... But considering that I do not interact with others that much and if so I ALWAYS use condoms ( a 25 years - 100 % adherence to this policy that had one and only one YET DRAMATIC exception - I've learned my lesson !)

I didn't know that the tissues at my bedside were at risk of infection !!!

So now my brains are fully loaded with ARVs: they'd better be protective !!And I hope that they are not the cause for that tension I keep having on the Jaw

Seen from my perspective the advantages are :- good for cholesterol- good for blood sugar- once-daily down the road- saves Isentress and PIs for future use (in case of resistance)- less CNS risk (read all those threads about Atripla...)(1 % vs 11 % for Efavirenz)

So far so good.

We are still waiting for the genotype (possible resistance)

BTW, the CD4 cell counts >400 cells/mm3 comes from the 2NN study. Since the >400 cells/mm3 has been established, less AEs had been seen in other studies, too.YET, reports from doctors in ressource limited settings where Viramune (nevirapine) is used regardless of this recommendation seem to contradict this increased liver toxicity risk.(eventhough, I doubt that in these settings they initiate often at above 400...)

If it were not for the above, I would have preferred I&T I now think he did not offer that because I&T is not yet in the recommended list for treatment naives here (it is in the US...)

I do not know how to put it. Let's be factualI went to the lab to inquire if the genotype that my Doctor ordered was done. I said I need the information because I need to schedule an appointment.They confirmed that the results had just been sent to him that very day. They would not give the results to me. I did not make an issue of that I was way too much under stress.

I got my blood drawn to get CD4 count and VL right at month 3 (started meds on June 9, blood work was on Sept 9)Got the results yesterday.

I hypothesized that if the CD4 count was stable more or less and VL going down then, I could be hopefull that the resistance test would come up clean.

Unfortunately, CD4 count is down to 550 (from a low 800 2 weeks before) and % is also a bit down (28 % down from 30 %) and VL slightly up 242 (vs 220 , 2 weeks ago)

The CD4 count drop is not small... I hope the resistance test shows something (even if it is bad news), because if it does not, then, well ... I do not know...

Doc has a lot of experience, so ... And I would not mind a switch. I think I 'd prefer a switch to a combo that it working poorly.

I do know I do not have much to fear and so on. For the last few weeks I have had good nights and no crying, no fainting , no nothing (but for a tension in the jaw that is slowly fading)

Today, I even had a tiny bit of discomfort in the liver area, which made me notice that have not had that for days...

While waiting for the lab there was that great looking guy who came in, he was JUST my type (and my taste is not one of the easiest), RIGHT ON; but I do not like to dream about the unreachable, I could not help my self, I guessed. He was on his way back. Had a eye contact first , then a second.

I was so depressed, I did not run after him. I regret that now. He's been on my mind since.

I stand on a razor edge between the prospects of success and that of failure.

Doc: I have one good news and one not so goodMe : shootDoc: the good news is that the genotype does not show any new resistance (as of end of July), bad news is that VL is somewhat high (242)Me: ...Doc: that is still within target, though, we 'll just monitor it a bit more closely, next CD4+VL in 6 weeks...

Side effects?: I still have this tension in the jaw muscle, may be a (tiny) bit less, a bit less constipated too, some times a bit itchy... Nothing elsewell, I do have something else: skin on the legs gets some tiny muscle contractions...repeateadly, erraticaly, like some allien is leaving underneath.He gave the name for it... said is has no clinical significanceMe : ...Doc: your side effects are an intellectual challenge to me (he smiles)Me (by myself): Well, doc, I am not here for your intellectual enjoyment !!!

I hope this regimen will work for me: it has proven good for me (blood sugar and colesterol profiles have improved and I do feel it)and can be once a day down the road...

If I need a switch he said Isentress is a good candidate eventhough it is twice a day. Same feeling here.

Discussed popularity of regimens, which, based on this forum, this Nevirapine + abacavir + 3TC is not the most common.

Doc: yes, I must admit. I only have 2 or 3 patients on that. And they are inherited patients (they came too him after starting treatment)(note: he has got a lot of patients and experience, I have checked that...)

WhAAAAAT I am the first patient you are initiating on this regimen ??

(No doubt, I feel nervous... I kind of knew it... Is he experimenting on me !!!???)

Discussed new meds/options, etc.

He then made a point, which, in my humble opinion makes a lot of sense about my combo (Viramune + Kivexa), which is not so common. This combo carries a long list of POTENTIAL side effects, it scared the S*t out of me...

The list itself is long, but, me, knocking wood, I am so far doing fine... A long list of possible side effects does not mean a high probability of getting SE. They are just very diverse. Atripla has a much shorter list, but as many as 20% seem to complain about the CNS SE.

The longer list may be one of the reasons why Viramune appears to be less popular amoung the people in this forum.

Another example: read the list of potential side effects ABACAVIR (which I am taking) is carrying. Sounds like a complete series of Dr HOUSE , MD, they are so many and so scary. They are not to be taken lightly.

Yet, in one study (don't remember which) over 500 naives initiated to ABACAVIR , only 4 got these SE (and in fact 2 of the patients, if I remember well had other conditions HVC, what have you, do not remember). This is LESS than 1% !!!

Doc said that some of his colleagues are teasing him for still prescribing Viramune

Sometimes a small study involving a mere hundred patients shows good results and, all of the sudden, this med becomes instantly popular (see QUAD), at the expense of the 'older' ones.

He said that MILLIONS of people are (or have) taking Viramune, daily, for years (it has saved millions of lives). If it were THAT bad it would show!

I thought that comment made a LOT of SENSE. A hell lot of sense...

I love the guy ... He is HUUUGE, I feel sorry for him when I see his HUUUGE fingers stricking his keyboard, He should ask Hagrid for a giant Wizard version.I can't even say how big he is, he's beyong my usual scale. He's got that deep, profound voice, that connects to people. Charming eyes too.

Doc: And also, you have Respiratory sinus arrhythmia (RSA)Me : .... (what the hell is that new thing ??)Doc: your heart speeds up when you breath in and slows down when you breath outMe : !!! Doc: It is usually found in adolescents or people with great control of stress (Me no kidding !!!)Me : well, there is still a lot of a teenager left in me (I was trying to be funny, - failed - but, this is quite true, in fact...)Doc: ...

(wikipedia says: The term sinus arrhythmia refers to a normal phenomenon of mild acceleration and slowing of the heart rate that occurs with breathing in and out. It is usually quite pronounced in children, and steadily decreases with age. This can also be present during meditation breathing exercises that involve deep inhaling and breath holding patterns.wikipedia adds: Adults in excellent cardiovascular health, such as endurance runners (my case?), swimmers, and bicyclists, are also likely to have a pronounced RSA.

So, this is pretty good news: Heart is in good shape... Come on sweety boys, this old fellow still young and H...y !

I started this thread because I could not find much on the Internet about this combo. I was kind of worried.

I am NOT worried any more... The slow virologic reponse was kind of anticipated (being older, etc...).

I'll carry on for the excitment of the (not so few) readers

also, did not cry during the interview (for the first time) : some progress on this front too...

Resistance or not ? : we still linger in the lymbs of the unknown... And it is quite enjoyable !

That chronic tension on the jaw (and sometimes brain fog) is a pain in the butt (well, no... in the jaw, but still...) Therefore, I have moved my Kivexa time upwards to PM intake. At first it seemed beneficial, but, now, I am not so sure. maybe slightly better. This problem arised 2 weeks after changing timing so I will give it some time and see if the timing change resolves it.

if THAT wasn't there (and such a low noise impairment is a real annoyance) I would dare say that my general sense of well being (say energy, strength, interest in things, etc...) is actually BETTER than before infection (sic...). Meds have improved my HDL and insulin/sugar resistance that are insidious age/aging effects.

I have much longer, efficient working days, much less naps (if ever) (and if so shorter); it is like the clock is ticking backwards. too bad this med-induced-stress-mimicking-effect is ruining the day(s)...Wait and see...

one funny thing, the other day, I was doing some internet search on Viramune (nevirapine) and ended up reading my own thread. I also found interesting things...

Several pharmacogenetic studies have revealed strong associations between specific human leukocyte antigen (HLA) alleles and the susceptibility to drug hypersensitivity. Recently, we reported HLA-B*3505 as a strong genetic biomarker for the nevirapine-induced skin rash in Thai population. Here, we developed a new HLA-B*3505 genotyping method by a combination of the Universal Invader assay and sequence-specific primer PCR. From the sequence alignment of 68 HLA-B alleles in the Thai population, we selected the two most discriminative SNPs (rs1140412 and rs4997052) as target SNP sites. When we carried out the assay using 324 Thai individuals, fluorescence intensities of HLA-B*3505-positive and HLA-B*3505-negative samples were apparently discriminated at the endpoint of the reaction. Our results were 100% concordant with those obtained by a sequence-based typing method. As our assay is simple and rapid, we believe our method will be a useful tool for pharmacogenetic testing of the nevirapine-induced skin rash.

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If I understand well, and if it works like the HLA B*5701 genotype screening now enforced for Abacavir, it would at the same time reduce the number of people iniated to Nevirapine (in the same fashion that less people are iniated to Kivexa than to its virologically quite similar Truvada), it would also reduce the incidence of skin rash SE, which from the user perspective, is good news !

Nevirapine forms the mainstay of our efforts to curtail the pediatric AIDS epidemic through prevention of mother-to-child transmission of HIV-1. A key limitation, however, is the rapid selection of HIV-1 strains resistant to nevirapine following the administration of a single dose. This rapid selection of resistance suggests that nevirapine-resistant strains preexist in HIV-1 patients and may adversely affect outcomes of treatment. The frequencies of nevirapine-resistant strains in vivo, however, remain poorly estimated, possibly because they exist as a minority below current assay detection limits. Here, we employ stochastic simulations and a mathematical model to estimate the frequencies of strains carrying different combinations of the common nevirapine resistance mutations K103N, V106A, Y181C, Y188C, and G190A in chronically infected HIV-1 patients naïve to nevirapine. We estimate the relative fitness of mutant strains from an independent analysis of previous competitive growth assays. We predict that single mutants are likely to preexist in patients at frequencies ( approximately 0.01% to 0.001%) near or below current assay detection limits (>0.01%), emphasizing the need for more-sensitive assays. The existence of double mutants is subject to large stochastic variations. Triple and higher mutants are predicted not to exist. Our estimates are robust to variations in the recombination rate, cellular superinfection frequency, and the effective population size. Thus, with 10(7) to 10( infected cells in HIV-1 patients, even when undetected, nevirapine-resistant genomes may exist in substantial numbers and compromise efforts to prevent mother-to-child transmission of HIV-1, accelerate the failure of subsequent antiretroviral treatments, and facilitate the transmission of drug resistance.

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The take-home message for me is not clear, but if I understand well, if a (drug resistant) mutant appears, it is because it pre-exists, and if so at a level fairly high, but not so high that it can be detected at pre-initiation genotype (where VL is 4-5 logs), but still fairly high and thus it should not be missed at a post-initiation genotype (mine was made at 600)and since no resistance was seen, then it makes me hopefull that there is no resistance

if I take my pretreatment numbers (non smoker, systolic 120, total cholesterol : 160 mg/dl HDL: 35 age : 48) and on borderline if diabetes (means I calculate with and without ...)

if I choose diabetes : no : NNH for abacavir and given patient profile is 141 (Framingham 5-years risk while on abacavir is 1,5%)if I choose diabetes : yes : NNH for abacavir and given patient profile is 62 (Framingham 5-years risk while on abacavir is 3.5% !

So my doc should certainly consider avoid ABC, but since he did not (obviously), I should certainly get nervous (which I did, obviously...)

BUT, if I take my latest numbers (under this combo : viramune + Kivexa (Epzicom), and since my lipid/sugar number have drastically IMPROVED (thanks to this combo, there is no other reason...)namely:(non smoker, systolic 110, total cholesterol : 199 mg/dl HDL: 66 age : 48) and clearly diabetes :no

In a rare twist of history one of my family members invited me to an open doors at our local NIH equivalent as part of a fund raiser. (that side of our family runs a foundation that donates a lot to cancer research)visitors were randomly directed to various labs and the lab tech/manager gave presentation about what they do.

The most unexpected thing of all is that, by the most unexpected chance, I was assigned to visit the very lab and receive explanations from the very same person that has signed off my genotype tests!...

That was emotionally hot. (one girl actually fainted during one of the conferences...). I, myself, was very unprepared too...

I've just got to see with my own eyes the very people who are doing this research here, in their working environment.

Actually a genotype test seems to be very labor intensive... And the equipment they use seems so basic (and ancient...) so much different than the luxury labs of big pharma.

there was a hands on on gel electrophoresis as part of the open doors (on a colorant not a real sample) and I volunteered.

I am still not UD ... (VL at 217 (log 2,34 at week 19 ...). Let's see what doc has to say:

I am usually looking forward to visits to my doc. Its some privileged moment, personal... I admire the guy, he is also so much the opposite of me

The mood was not to good. There was a bit of a commotion in the waiting room with one patient sharing (loudly) his personal experience with rash, lack of adherence, sickness, etc.I was not in mood to hear that...

Doc: got your VL results. Could not sleep half of the night because of thatMe: we're even, I could not sleep the other halfDoc: I have not told you which half I could not sleepMe (trying to save the day) : don't bother, I could not sleep neither halvesDoc: ...Me : ...

Doc: checkpoint is VL < 50 at 6 months. Your VL is somewhat high that is what worries me.Me : ...Doc: we are not yet at Month 6, so let's carry on, we are not yet out of the set guidelinesMe: I agreeDoc: next blood draw Dec. 6. VL below 50. That's our red line. Not negotiable. Resistance is too serious an issue.Me : I know

His eyes are daring me. I do not care, I do not look at him in the eyes. I can only look at his huge fingers on his keyboardThat is because I know we are not going to be below 50 on DEC. 6.

I also know why, but I am not saying anything.

I pretty much liked the fact that he could not sleep because of me. Liked to share the pain, the distress, the crying at nights, the praying (is there a prayer against resistance?).

Me : do not worry, I am comfortable with whatever comes up...

Yes, let's see what you've got under the hood when you will have to declare me a 'virologic failure'

Next visit will be a tough one. I do not mind a man-to-man, Will see if you duck in or got some balls ... Herr DoKtor !

And, at long last, I am starting to find this interesting and exiting!

Eric, you had a genotype test that only revealed the T215E mutation which only rules out AZT and d4T. So, unless you've not been adherent, I wouldn't think resistance was your issue. Your VL is practically UD now. On tests that were still in use only a few years ago, you WOULD be UD NOW. Try to not sweat it so much. Chances are very good that you'll be UD very soon.

"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts